QS201 - Comparison of postoperative morbidity following total colectomy with ileorectal anastomosis versus proctocolectomy with ileal pouch-anal anastomosis in Familial Adenomatous Polyposis

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Purpose/Background: Surgery for patients with familial adenomatous polyposis (FAP) requires a balance between minimizing cancer risk and quality-of-life preservation, and it generally involves either a total abdominal colectomy with ileorectal anastomosis (TAC/IRA) or total proctocolectomy with ileal pouch-anal anastomosis (TPC/IPAA). Prior studies have compared functional and technical outcomes related to TAC/IRA versus TPC/IPAA; however, these studies are dated with many surgeries involving laparotomies as opposed to a minimally invasive surgical (MIS) approach. MIS for FAP patients is more common in current practice, but there have been no studies comparing technical outcomes between the two surgeries.

Methods/Interventions: Our IRB-approved Inherited Colorectal Cancer Registry was used to retrospectively identify all patients with FAP who underwent an index TAC/IRA or TPC/IPAA between 2008-2023 at our institution. Data including patient demographics, surgical technique, 30-day and 90-day complications, readmission, and reoperation was obtained from the database and supplemented by chart review. Complications were scored using the Clavien-Dindo Classification.

Results/Outcomes: A total of 217 patients underwent surgery: 146 (67.3%) TAC/IRA and 71 (31.7%) TPC/IPAA; 106 (49%) females, median age at index surgery 23 (range 10-72). MIS was used for 185 (85.3%) patients including 129 (88.3%) in the TAC/IRA group and 56 (78.9%) in the TPC/IPAA group (p=0.07). 3 (2.0%) diverting loop ileostomies were created with TAC/IRA compared to 62 (87.3%) with TPC/IPAA (p < 0.0001). There was no significant difference in the number of patients who developed a complication within 30 days (p>0.99) or within 90 days (p=0.56). Only 16 (11.0%) patients undergoing TAC/IRA and 13 (18.3%) undergoing TPC/IPAA developed a severe complication (Clavien-Dindo Grade 3a or above, p=0.14). The most common complication was ileus [50 (34.2%) TAC/IRA; 15 (21.1%); TPC/IPAA] which occurred more frequently after TAC/IRA (p=0.06). The most common severe complication was anastomotic leak which occurred in 7 (4.8%) patients after TAC/IRA and 5 (7.0%) after TPC/IPAA (p=0.53). Small bowel obstruction was significantly more common after TPC/IPAA (15.5%) vs. TAC/IRA (1.4%), and obstructions requiring reoperation were the second most common severe complication. 2 (1.4%) mortalities occurred after TAC/IRA (1 – cardiac arrest, 1 – sepsis due to pneumonia). 0 mortalities occurred after TPC/IPAA. Furthermore, patients who had a TPC/IPAA were more likely to be readmitted at 30 days (p=0.004) and 90 days (p=0.0005) and were more likely to require reoperation at 90 days (p=0.02). The most common reason for reoperation after TPC/IPAA was small bowel obstruction which occurred in 7 patients (9.9%).

Conclusion/Discussion: FAP patients who undergo a TPC/IPAA have increased short term post-operative morbidity compared to a TAC/IRA; however, there is no significant difference in the number or severity of complications between the two surgeries. Ileus is a common complication post-operatively and more frequently occurs after TAC/IRA. Small bowel obstruction occurs more often after TPC/IPAA and is a common reason for reoperation in this patient group. Overall, a minimally invasive approach is safe for both TAC/IRA and TPC/IPAA, and both surgeries have individual risks and benefits which should be considered during surgical decision making.